AM. J. DRUG ALCOHOL ABUSE, 17(1), pp. 13-26 (1991)
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Crack Cocaine Use: A Review of Prevalence and Adverse Effects* Reginald G.Smart, PhD Prevention Studies Department Addiction Research Foundation Toronto, Ontario M5S 2S1, Canada
ABSTRACT Crack is a potent form of cocaine which results in rapid and striking stimulant effects when smoked. This paper reviews epidemiological research on the extent of use as well as reports of adverse effects. Crack is used by a small minority of adult and student populations but by a large proportion of cocaine users and heavy drug-using groups. Use does not appear to be increasing in general populations, but there are no trend studies for high-risk groups. Crack users tend to be young, heavy polydrug users, many of whom have serious drug abuse problems. The adverse reactions to crack are similar to those of cocaine and include effects on offspring, neurological and psychiatric problems, as well as pulmonary and cardiac abnormalities. However, two adverse reactions unique to crack have been reported. One relates to lung infiltrates and bronchospasm. The other involves neurological symptoms among children living in crack smoke-filled rooms. There is a need for improved treatment and preventive programs for crack use.
INTRODUCTION Cocaine abuse has developed rapidly in North America during the past 10 years. Traditionally, users sniffed a crystalline form of cocaine and only a few heavy users injected it [ l , 21. However, in about 1985 “crack” cocaine was developed, and it has become the most popular form for many cocaine users in the United States [3, 41. Since 1986, a variety of studies have been made of the extent of *The views expressed in this paper are those of the author and do not necessarily reflect those of the Addiction Research Foundation.
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crack use in different populations. In addition, many clinical case histories have been reported describing the effects of crack use by mothers and their offspring, as well as cases of serious neurological, psychiatric, cardiac, and pulmonary adverse reactions. Many such reactions are similar to those for other types of cocaine, but some are probably unique to crack. No recent review of survey and clinical case history research on crack seems to be available. Some of the relevant material is in unpublished reports, or letters to journal editors, and hence may not be readily available to those concerned with crack. This paper reviews research on levels of crack use, the characteristics of users, and reported adverse reactions to crack. Crack is produced by mixing cocaine crystal or powder (cocaine hydrochloride and adulterants) with water and baking soda or sodium bicarbonate. The mixture is boiled until the water has evaporated and a waxy substance remains in rocks or chunks [4]. It contains alkali and cocaine, and unlike the cocaine powder, it is readily burned to make smoke at moderate temperatures [ 5 ] . Usually, crack is smoked in special glass pipes, put on cigarettes [3,4], or even into nontobacco cigarettes [6]. Because crack produces small particles when smoked, it is absorbed rapidly through the lung and produces its peak high about 6-8 minutes after taking it [5]. The effects are similar to those for intravenous doses and appear much more quickly than for the traditional cocaine sniffing. The rapid onset of effects is probably a factor in crack’s high level of addictive potential [ 1, 41, as well as the adverse reactions often seen. Sometimes crack is confused with freebase cocaine, especially in papers on adverse effects. Freebase is cocaine from which adulterants have been removed, usually by boiling with an alkali and ether. However, crack is a smokable form of street cocaine from which adulterants have not been removed [3].
PREVALENCE OF CRACK USE Because of its relative newness in the drug-taking scene, only a few studies have been made of crack use in large populations or high-risk groups. Table 1 summarizes the available studies; only one of adults seems to be available. Smart and Adlaf [7] found that 0.7% of adults in Ontario had used crack or about 12.0% of those who had tried cocaine in all its forms. Several studies have been made of crack use among students. Smart and Adlaf [8] found in 1987 that 1.6% of students (aged 13-19) had used crack in Ontario; about 24.2% of all cocaine users had tried crack. Among students in British Columbia [9] aged 14-18, about 1.6% reported crack use. Rates of use were much
CRACK COCAINE USE
15
Table 1. Frequency of Crack Use in Various Survey Population and High-Risk Groups ~~
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Authors
N
Sample
Place
~~
Year
Rate of use
1987
0.7% (ever)
Smart and Adlaf [7]
1,040
Adults 18 and over household sample
Ontario
Smart and Adlaf [8]
4,267
Students (aged 13-19), Grades 7-13 classroom sample, stratified
Ontario
14,750
Students (aged 14-18), Grades 8-12
British Columbia
1988
1.6
Senior students in high schools
U.S.A. national sample
1987 1988
5.6 1.4 (lifetime)
1986 1987 1988
4.1 4.0 3.1 (past Year)
1987 1988
1.5 1.6 (past 30 days)
Chamberlayne et al. [9]
Johnston ef al. [lo]
Johnston et al. [ 101
College students, 1-4 years beyond high school
U.S.A. national sample
1986 1987 1988
1.3 2.0 1.4 (past year)
Washton er al. [4]
458
Cocaine abusers calling cocaine hotline
U.S.A
1986
32.0% (ever)
Inciardi [3]
254
Street youths involved in drugs and crime
Miami
1986
95.5 (tried) 87.3 (regular use)
Wish er al. [ 1I]
250
Intensive supervision of probationers
Brooklyn
1986
38.0% (ever)
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higher among seniors in American high schools. In 1987, 5.6% had used cocaine in their lifetime, 4.0% in the past year, and 1.5% in the past month. However, rates of use were much lower among college students; only 2.0% had used in the past year. Among high school seniors, about 27.1 % of students who reported some cocaine use (lifetime) reported crack use. Only Johnston ef al.’s annual studies [lo] of high school seniors give any indication of trends in crack use. Both crack and cocaine use dropped significantly between 1987 and 1988. Crack was not included in the surveys before 1986, and hence data are not available for the early years of the crack epidemic. However, this study did show a large increase in cocaine smoking between 1983 and 1986. As expected, crack use is very high among high-risk or known drug-using groups. For example, Washton et al. [4] found that 32% of cocaine users calling a cocaine hotline had used crack. One study of intensive supervisionprobationers in Brooklyn showed that 38 % had used crack [111. However, 96% of street youths involved in drugs and crime in Miami used crack, often very heavily, although much of their cocaine use does not involve crack [3]. In general, crack use rates are low in general populations, far lower than for alcohol, cannabis, or tobacco, and even for the use of cocaine in other forms. However, rates of crack use are much greater in some high-risk groups, although in some a minority of cocaine users have tried crack.
CHARACTERISTICS OF CRACK USERS Several studiesof crack users have establishedthat they share many characteristics with users of other types of cocaine. Typically, they are young males who are heavy users of cocaine and other drugs. For example, the study of adults in Ontario [8] established that most crack users were male, aged 18-29, as were most other cocaine users. Many were heavy users of cannabis, sleeping pills, and alcohol. Smart [12] compared student crack users with other cocaine users and with noncrack and cocaine users. Crack users were younger than the other two groups (average age 14.5), and about 75% were male. They were much more likely than nonusers of cocaine to have used all illicit drugs, but especially cannabis, stimulants, and hallucinogens. They were also more likely to smoke cigarettes and drink alcohol frequently. As expected, crack users were similar to other cocaine users in their heavy use of alcohol and most illicit drugs. However, they were more likely than cocaine users to have used PCP, tranquilizers, stimulants, heroin, and glue. Their relative youth and heavy drug use indicates that many student crack users will have problems requiring treatment.
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CRACK COCAINE USE
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The studies of American high school seniors in 1987 [9] also found that crack users are more often male, although use rates for females are relatively close (4.8% males vs 3.1 % females). About one-third of those who had tried crack had stopped using it. Regional differences in crack use were about the same as for cocaine with the highest rates in the West and Northeast, and the lowest in the South. Rates of use were higher in large cities than small cities or nonurban areas, but the differences were not very large. Students who were not intending to go to college were more often users than those who did intend to go to college. Callers to the cocaine hotline who reported crack use [4] were mostly male (72%) and aged 20 to 39 (94%). Most had switched to crack after trying intranasal cocaine. About 82 % reported a compulsion to use the drug, and hence the callers were primarily dependent upon cocaine and not recreational users. Of course, callers to the hotline were primarily seeking help or advice about drug problems and would be expected to be heavier users than those found in general population surveys. Data on crack users in treatment are not very extensive yet as insufficient time has elapsed since crack became popular. One study of 3 1 crack users in a Brooklyn center for medical detoxification [13] found that the ratio of males to females was closer than in most surveys (almost 1: 1). The mean age was 30.6 years. The majority were from Black or Hispanic minorities. Only 32.5% were currently employed, but about 25 % had some employment in the past year. Many had been exposed to domestic violence or alcoholism. In addition, 39% met the DSM 111 criteria for major depression or dysthmic disorder. Earlier studies 1141 found that about a third of cocaine users in treatment are severely depressed. Crack users in other types of treatment in different locales may, of course, show other sociodemographic and psychological characteristics from those in this study.
EFFECTS OF CRACK COCAINE Cocaine increases heart rate, pulse, blood pressure, respiration rates, and creates a general autonomic stimulation. It also creates vasoconstriction. The psychological effects of cocaine are feelings of stimulation, euphoria, hyperactivity, increased talkativeness, and energy [l-31. However, several cases have been reported where cocaine had a calming effect on anxiety or appeared to have a sedative effect [15]. Numerous neurological problems from cocaine use have appeared. For example, CNS stimulation, decreased cerebral metabolism and cases of seizures [11, intracerebral hemorrhage [17], sudden death [16,18], psychosis [19], stroke [20],
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and cardiac abnormalities [21] have been reported from cocaine use. In addition, maternal cocaine use has resulted in decreased gestational age [22], low birth weight, and increased congenital abnormalities in offspring [23]. Because crack cocaine is potent and rapidly absorbed, its effects on cardiovascular, neurological, and psychological functioning should be more rapid than for intranasal cocaine. Probably the effects are stronger and more rapid than some intranasal cocaine users have seen in the past, and certainly more than first time users have seen. Crack cocaine should produce essentially the same adverse reactions of cocaine; however, such reactions may be more common or more severe. Since crack cocaine is smoked and particles are released into the ambient air, passive cocaine inhalation by nonusers is possible.
ADVERSE EFFECTS OF CRACK ON OFFSPRING OF USERS Several studies of the effects of crack use on offspring have been reported. They are summarized in Table 2. Bateman and Heagarty [24] described four cases involving transient neurological symptoms such as drowsiness, unsteady gait, seizures, etc. in children exposed to passive crack inhalation by parents or other persons. The cases appear to have involved heavy crack smoking in closed rooms and illustrate a special problem for crack which does not exist for other forms of cocaine. LeBlanc et al. [25] described cases of tremulousness, imtability, and muscular rigidity among 38 infants of mothers who used crack during pregnancy. Mothers denied using other forms of cocaine or narcotic drugs. However, four of the mothers were also users of marijuana, five drank alcohol regularly, and four were smokers. Urinalyses were done for 20 infants, and cocaine was present in the urine of 10 symptomatic and 9 asymptomatic infants. Hence it appears that cocaine does not always produce neurological or behavioral abnormalities. As with many crack case histories, the contribution of drugs other than crack is difficult to assess. An attempt to control drug effects was made in the study by Cherukuri et al. [26]. They studied 55 women who used crack cocaine (but not narcotics) during pregnancy, and 55 who used no drugs. The frequency of cocaine use is not stated. Crack-exposed infants had lower gestational age and birth weight, smaller head circumference, and premature rupture of membranes. However, there was no difference in the meconium or in fetal distress. Unfortunately, the possible contribution of other drugs such as alcohol, cannabis, etc. is not clear. In addition, 60% of the crack-using mothers had no prenatal care, and the authors recognize
CRACK COCAINE USE
19
Table 2. Adverse Reactions to Crack in Offspring of Users
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~~~~~~~
~
~~
~
~
~
~~
Authors
N
Patient characteristics
Diagnosisisymptoms
Bateman and Heagarty [24]
2
Girl aged 3% months, boy aged 2 years and 3 months
Transient neurological symptoms (drowsiness, unsteady gait)
2
Boy aged 9 months, boy aged 3 years and 1 1 months
Transitory seizures
LeBlanc ef al. [25]
38
Infants of crack-abusing mothers
Possible influence of alcohol, tobacco, and marijuana by mothers
Cherukuri et al. [26]
55
Females admitting crack use in pregnancy compared to 55 not using
Tremulousness ( n = 15) Irritability ( n = 16) Muscular rigidity ( n = 11) Crack-using mothers more often had early deliveries. Infants had intra-uterine growth retardation, smaller head circumference, and ruptured membranes. 60% of crack-using mothers had no prenatal care Fatal battering by crack-using adults
None stated
Press [27]
3
Children aged 1 month, 2 years, 3 years
Other drug None
Unclear
the possible influence of malnutrition and other social factors. However, they argue that the study underestimates the effect of crack on perinatal outcomes. Violent, aggressive behavior has often been reported to be an outcome of cocaine use [1,2]. A brief report by Press [27] describes the fatal battering of three children aged 1 month to 3 years by crack-using adults (presumably family members). Details about the extent of crack use involved or whether the batterings occurred during such use are not given. The question of the role of other drugs was not raised.
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NEUROLOGICAL AND PSYCHIATRIC ADVERSE EFFECTS Cocaine use has been associated with neurological complications such as seizures [l, 151 and cerebral hemorrhages [17]. However, a variety of neurological problems have also been seen after crack use, and these are summarized in Table 3. Recently, Mody et al. I281 described nine cases of neurological disturbances among crack users. The majority seem to have appeared in heavy users, but in at least three cases they appeared after the first crack use. In most cases the role of other drugs is not clear; but in a few, heavy alcohol use was concomitant with crack use. In three cases the neurological symptoms were almost instantaneous after crack use, but in others there were delays of several hours. There were three cases of generalized tonic-clonic seizures, three of intraparenchymalhemorrhage, and one of ischemic infarct in the fronto-temporal area which are attributed only to cocaine. There are two cases of numbness, arm and leg weakness or paralysis, both probably involving transient cardiac or neurological problems. In one case, recurrent episodes of motor seizures followed the concurrent use of crack and six cans of beer. In another case a crack user who was also an alcoholicexperienced transient ischemic attacks, marked burning sensations, tightening of facial muscles, spinning sensations, buzzing in the ears, and double vision. To illustrate the problems of deciding how difficult it is with mutliple drug users to attribute symptoms to a single drug, it is useful to examine the case presented by Golbe and Merkin [29]. They reported on a 27-year-old man who suffered a cerebral infarction after smoking two vials of crack of unknown size. He drank ‘/z pint of vodka and 2 pints of wine at the same time as he had the crack. Usually, he drank about 150 mL ethanol week (11 drinks) and smoked a pack of cigarettes each day. In addition, there were signs that he had a serious alcohol problem and had been a heavy user of intranasal cocaine. It has been pointed out [30] that the symptoms seen could be due to the use of several drugs other than crack. Although the Golbe and Merkin case may have involved drugs other than crack, similar cases reported by Levine et al. [31] do not. They reported on three cases of headache, language and visual disturbances, two of which did not involve other drugs. However, in the third case the patient had taken an “unknown” quantity of alcohol with the crack. Several studies have reported psychiatric problems after crack use. For example, Price and Giannini [32] reported panic attacks in an unknown number of patients. However, Washton ef al. [4] found that a majority of crack users calling a hotline number reported severe depression, paranoia, irritability, and chest congestion after crack use. Fewer reported chronic cough, violent behavior,
CRACK COCAINE USE
21
and suicide attempts; the fewest reported brain seizures. However, the contribution of alcohol and other drugs is not clear.
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CRACK, HIV INFECTION, AND SEXUALLY TRANSMITIXD DISEASES It has been well established that intravenous cocaine use significantly increases the risk of HIV infection [33, 341. Chiasson et al. [33] found that 35% of daily cocaine users were HIV positive. Cocaine use, syphilis, and HIV positivity were more common among Blacks than Whites. In fact, a genetic theory has been advanced to account for the differences between Blacks and Whites in sero positivity [35]. However, the studies of Chiasson et al. [33] and Hahn et al. [34] refer primarily to intravenous drug use. Crack is not mentioned as a cocaine delivery method associated with HIV positivity or syphilis, nor has any study been found linking these problems. Doubtless, some of the cocaine injectors use crack, but this is unlikely to relate to HIV risk or sexually transmitted diseases. In fact, De Jarlais and Friedman suggested [36] that if cocaine injectors were to switch to crack, that would reduce their HIV risk; however, he found that very few in New York City had done so yet.
OTHER MEDICAL ADVERSE EFFECTS A few studies have reported serious medical consequences of crack use. One case has been seen in which a 25-year-old man used freebase twice in the same day [37]. On admission, he had heart block with dyspnea and chest pain. Similar symptoms were reported for six other patients who used cocaine intravenously or intravasally. Zamora-Quezada er al. [38] reported on skin rash and muscle necrosis following crack use. It was associated with reticulitis, myalgias, and muscle weakness. Pulmonary disease called “crack lung” has been seen after crack use. Kissner et at. [39] treated a 47-year-old woman who had fever, transient lung infiltrates, and brochospasm after a week of heavy crack use. The patient also smoked 1-3 packs of cigarettes per day. “Crack” produces most of the adverse neurological, psychiatric, and cardiac effects of cocaine. However, at least two types of reaction are confined to crack. The pulmonary syndrome called “crack lung” will not occur with other types of cocaine administration, nor will the neurological symptoms seen in children breathing the ambient air in rooms filled with crack smoke.
Golbe and Merkin (291
Infarction of cerebral artery, left side weak, hemirparesis hemianopia, and headache
Generalized tonic-clonic seizures
Male aged 31
1
Male aged 27
Generalized tonic-clonic seizures
Females aged 25 and 27
2
1
Ischemic infarct in left fronto-temporal area Intraparenchymal hemorrhage
Maleaged28
Recurrent episodes including burning sensation in eye, tightening of facial muscles, twisting of mouth, spinning sensation, buzzing in ears, and double vision
Males aged 30 to 34
Male aged 45, chronic alcoholic
1
Several episodes of arm and leg weakness, decreased pain, and touch sensations
1
Male aged 22 smoking crack for first time
I
Pain between shoulders, numbness, weakness, paralysis, and cardiac arrest
Diagnosis/sy mptoms
3
Male aged 24 smoking crack for first time
1
Mody cr al. 1281
Patients characteristics
N
Authors
Table 3. Adverse Neurological, Psychiatric, and Medical Reactions to Crack
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with heavy drinking, use of ibuprofen, smoking
Crack use concomitant
Role of alcohol not ClW
Not stated
Not stated
Other drugs
z
2
3-
rn
Male aged 48
1
1
1
1
Zamora-Quezada er al. [38]
Kissner er al. [39]
Female aged 47
Female aged 20
Maleaged25
caine hotline number
144 crack users calling a co-
No information
Male aged 25
1
1
Male aged 27
1
h e r er al. [37]
Washton er al. [4]
Price and Giannini [32]
LRvine et af. [31]
3 episodes of dyspnea, cough, fever, pulmonary infiltrates, and bronchospasm
Skin rash on lower and upper extremities, reticulitis, myalygias, acroyanosis, and muscle weakness
Chest pain, dyspnea, syncope, and complete heart block
Chest congestion (64%). chronic cough (40%). brain seizures (7%),sever depression (85%), irritability (78%). paranoia (65%), loss of sexual violent desire (58%), memory lapses (a%), behavior (31%), and suicide attempts (18%)
Panic attacks
Headache, nausea, slurred speech, ataxia, and blurred vision
Headache, altered vision, and multifocal abnormalities
loss, and languaged disturbance
Left cortical infarct with headache, hemisensory
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Patient smoked 1-3 packs of cigarettes per day
Not stated
Not stated
Unclear
Not stated
None
Alcohol
None
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Since crack users tend to be users of many illicit drugs as well as heavy drinkers, it is difficult to be sure that all of the reported adverse reactions are due to crack. However, the literature clearly suggests that use by mothers leads to abnormalities in offspring and to various neurological, psychiatric, and cardiac problems in users. Although the number of reported adverse reactions is small, it is growing rapidly. Almost all of the reactions involve male users and mostly heavy users of cocaine. However, there are several cases where the reaction occurred among persons using small amounts and taking crack for the first time. Methods of prevention and treatment of crack use are still needed. No specific methods of treatment have been evaluated for crack users, and most probably receive the usual treatment for cocaine abusers. As crack users tend to be heavy users of many drugs as well as cocaine, they may be more difficult to treat than the average cocaine user. There is a need to educate users and potential users about the serious and unpredictable effects of crack. At least one education program has been developed for crack [40], and it has been used with students in Florida. Effective programs at the school and community levels will certainly be needed in areas where crack use is endemic, but most existing programs seem to pay little attention to crack. There is also a need to monitor changes in levels of crack use, especially in heavy drug-using populations and among young people. REFERENCES [l] Siegel, R. K.,Cocaine smoking, Psychoactive Drugs 14:271-359 (1982). [2] Erickson, P. G., Adlaf, E. M., Murray, G. F., et al., 7he Steel Drug: Cocaine in Perspective, Lexington Books, Lexington, Massachusetts, 1987. [3] Inciardi, J. A., Beyond cocaine: Basuco, crack and other coca products, Contemp. Drug Probl. 14:46-492 (1987). [4] Washton, A. M., Gold, M. S., and Pottash, A. C., “Crack,” early report on a new drug epidemic, Postgrad. Med. 80:52-58 (1986). [5] Snyder, C. A,, Wood, R. W., Graefe, J. R., et al., Crack smoke is a respirable aerosal of cocaine base, Pharmacol. Biochem. Behuv. 29:93-95 (1988). 161 Cone, E. J., and Hemmingfeld, J. E., Premier “smokeless cigarettes” can be used to deliver crack, J. Am. Med. Assoc. 261:41 (1989). [7] Smart, R. G., and Adlaf, E. M., Alcohol and Orher Drug Use among Ontario Adults 1977-1987, Addiction Research Foundation, Toronto, 1987. [8] Smart, R. G .,and Adlaf, E. M., Alcohol and Other Drug Use among Ontario Students in 1987, and Trendr Since 1977, Addiction Research Foundation, Toronto, 1987. [9] Chamberlayne, R., Kierans, W., and Fletcher, L., British Columbia Alcohol and Drug Probl e m Adolescent Survey: 1987, British Columbia Ministry of Health, Victoria, 1988. [ 101 Johnston, L. D., O’Malley, P. M., and Bachman, J. G., Drug Use among American High School Studenrs, College Srudents, and Orher Young Adults: National Trendr through 1987, Washington: National Institute on Drug Abuse, Washington, D.C., 1987.
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[ I l l Wish, E. D., Cuadrado, M., and Martorana, J. A,, Estimates of drug use in intensive probationers: Results from a pilot study, Fed. Probat. W4-16 (1986). 1121 Smart, R. G., Crack cocaine use in Canada: A new epidemic?, Am. J. Epidemiol. 127: 1315-1317 (1988). [ 131 Wallace, B. C., Cocaine dependence treatment on an inpatient detoxification unit, J. Substance Abuse Treatment 4:85-92 (1987). [I41 Gawin, F. H., and Kleber, H. D., Abstinence symptomatology and psychiatric diagnosis in cocaine abusers: Chemical observations, Arch. Gen. Psychiarry 43:107-1 13 (1986). [IS] Byck, R., Cocaine Papers: Sigmund Freud, New American Library, New York, 1974. [I61 Wetli, C. V., and Wright, R. K., Death caused by recreational cocaine use, J. Am. Med. Assoc. 241~2519-2522 (1979). [I71 Schwartz, K. A., and Cohen, J. A,, Subarachnoid hemorrhage precipitated by cocaine snorting, Arch. Neurol. 41:705 (1984). [I81 Smart, R. G., and Anglin, L., Do we know the lethal dose of cocaine?, J. Forensic Sci. 32:303-311 (1987). [I91 Post, R. M., Cocaine psychoses: A continuum model, Am. J. Psychiatry 132:225-231 (1975). [20] Brust, J. C., and Richter, R. W., Stroke associated with cocaine abuse?, N. Y. Srare J . Med. 77:1473-1475 (1977). [2l] Howard, R. E., Heuter, D. C., and Davis, G. D., Acute myocardial infarction following cocaine abuse in a young woman with normal coronary arteries, J. Am. Med. Assoc. 254:95-96 (1985). [22] MacGregor, S. N., Chasnoff, I. J., and Rosner, M., Cocaine use during pregnancy: Adverse perinatal outcome, Am. J. Obsrer. Gynecol. 157:686 (1987). [23] Bingol, N., Fuchs, M., Diaz, V., er al., Teratogenicity of cocaine in humans, J. Pediarri. 110:93 (1987). [24] Bateman, D. A,, and Heagarty, M. C., Passive freebase cocaine (crack) inhalation by infants and toddlers, Am. J. Dis. Child. 143:25-27 (1987). [25] LeBlanc, P. E., Parekh, A. I . , Naso, B., er al., Effects of intrauterine exposure to alkaloidal cocaine (crack), Am. J. Dis. Child. 141:937-938 (1987). [26] Cherukuri, R., Minkoff, H., Feldman, J., er al., A cohort study of alkaloidal (crack) in pregnancy, Obsrer. Gynecol. 72: 147-151 (1988). [27] Press, S., Crack and fatal child abuse, J . Am. Med. Assoc. 260:3132 (1988). [28] Mody, C. K., Miller, B. L., McIntyre, H.B., er al., Neurologic complications ofcocaine abuse, Neurology 38:1189-1193 (1988). [29] Golbe, L. I., and Merkin, M. D., Cerebral infarction in a user of free-base cocaine (crack), Neurology 36:1602-1604 (1986). [30] Levine, S. R., Washington, J. M., Moen, M., et al., Crack associated stroke, Neurology 37: 1093 (1987). [31] Levine, S. R., Washington, J. M., Jefferson, M.F., etal., “Crack” cocaine associatedstroke, Neurology 37:1849-1853 (1987). [32] Price, W. A., and Giannini, A. J . , Phencyclidine and “crack” precipitated panic disorder, Am. J. Psychiarry 144:5 (1987). 1331 Chiasson, R. E., Bacchetti, P., Osmond, D., et al., Cocaine use and HIV infection in intravenous drug users in San Francisco, J . Am. Med. Assoc. 261:561-565 (1989). 1341 Hahn, R. A., Onorato, I. M., Jones, S . , et al., Prevalence of HIV infection among intravenous drug users in the United States, J . Am. Med. Assoc. 261:2677-2684 (1989). 135) Watters, J. K., Observations on the importance of social context in HIV transmission among intravenous drug users, J. Drug Issues 19:9-26 (1989). 1361 De larlais, D. C., and Friedman, S. R., Intravenous cocaine, crack and HIV infection, J. Am. Med. Assoc. 259: 1945-1946 (1988).
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[37] Isner, J. M., Estes, M., Thompson, P. D., et al., Acute cardiac events temporally related to cocaine abuse, N. Engl. J. Med. 3151438-1443 (1986). [38] Zamora-Quezada, J. C., Dinerman, H., Stadecker, N. J., et al., Muscle and skin infarction after freebasing cocaine (crack), Ann. Intern. Med. 108:564-565 (1988). [39] Kissner, D. G., Lawrence, W.D., Selis, J. E., er al., Crack lung: Pulmonary disease caused by cocaine abuse, Am. Rev. Respir. Dis. 136:1250-1252 (1987). [ a ] Rohrer, G. E., Hardley, R., Riordan, G. J., et al., Crack cocaine education in the public schools: A treatment center and the schools unite, J. Alcohol Drug Educ. 32:65-70 (1987).
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Crack Cocaine Use: A Review of Prevalence and Adverse Effects* Reginald G.Smart, PhD Prevention Studies Department Addiction Research Foundation Toronto, Ontario M5S 2S1, Canada
ABSTRACT Crack is a potent form of cocaine which results in rapid and striking stimulant effects when smoked. This paper reviews epidemiological research on the extent of use as well as reports of adverse effects. Crack is used by a small minority of adult and student populations but by a large proportion of cocaine users and heavy drug-using groups. Use does not appear to be increasing in general populations, but there are no trend studies for high-risk groups. Crack users tend to be young, heavy polydrug users, many of whom have serious drug abuse problems. The adverse reactions to crack are similar to those of cocaine and include effects on offspring, neurological and psychiatric problems, as well as pulmonary and cardiac abnormalities. However, two adverse reactions unique to crack have been reported. One relates to lung infiltrates and bronchospasm. The other involves neurological symptoms among children living in crack smoke-filled rooms. There is a need for improved treatment and preventive programs for crack use.
INTRODUCTION Cocaine abuse has developed rapidly in North America during the past 10 years. Traditionally, users sniffed a crystalline form of cocaine and only a few heavy users injected it [ l , 21. However, in about 1985 “crack” cocaine was developed, and it has become the most popular form for many cocaine users in the United States [3, 41. Since 1986, a variety of studies have been made of the extent of *The views expressed in this paper are those of the author and do not necessarily reflect those of the Addiction Research Foundation.
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crack use in different populations. In addition, many clinical case histories have been reported describing the effects of crack use by mothers and their offspring, as well as cases of serious neurological, psychiatric, cardiac, and pulmonary adverse reactions. Many such reactions are similar to those for other types of cocaine, but some are probably unique to crack. No recent review of survey and clinical case history research on crack seems to be available. Some of the relevant material is in unpublished reports, or letters to journal editors, and hence may not be readily available to those concerned with crack. This paper reviews research on levels of crack use, the characteristics of users, and reported adverse reactions to crack. Crack is produced by mixing cocaine crystal or powder (cocaine hydrochloride and adulterants) with water and baking soda or sodium bicarbonate. The mixture is boiled until the water has evaporated and a waxy substance remains in rocks or chunks [4]. It contains alkali and cocaine, and unlike the cocaine powder, it is readily burned to make smoke at moderate temperatures [ 5 ] . Usually, crack is smoked in special glass pipes, put on cigarettes [3,4], or even into nontobacco cigarettes [6]. Because crack produces small particles when smoked, it is absorbed rapidly through the lung and produces its peak high about 6-8 minutes after taking it [5]. The effects are similar to those for intravenous doses and appear much more quickly than for the traditional cocaine sniffing. The rapid onset of effects is probably a factor in crack’s high level of addictive potential [ 1, 41, as well as the adverse reactions often seen. Sometimes crack is confused with freebase cocaine, especially in papers on adverse effects. Freebase is cocaine from which adulterants have been removed, usually by boiling with an alkali and ether. However, crack is a smokable form of street cocaine from which adulterants have not been removed [3].
PREVALENCE OF CRACK USE Because of its relative newness in the drug-taking scene, only a few studies have been made of crack use in large populations or high-risk groups. Table 1 summarizes the available studies; only one of adults seems to be available. Smart and Adlaf [7] found that 0.7% of adults in Ontario had used crack or about 12.0% of those who had tried cocaine in all its forms. Several studies have been made of crack use among students. Smart and Adlaf [8] found in 1987 that 1.6% of students (aged 13-19) had used crack in Ontario; about 24.2% of all cocaine users had tried crack. Among students in British Columbia [9] aged 14-18, about 1.6% reported crack use. Rates of use were much
CRACK COCAINE USE
15
Table 1. Frequency of Crack Use in Various Survey Population and High-Risk Groups ~~
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Authors
N
Sample
Place
~~
Year
Rate of use
1987
0.7% (ever)
Smart and Adlaf [7]
1,040
Adults 18 and over household sample
Ontario
Smart and Adlaf [8]
4,267
Students (aged 13-19), Grades 7-13 classroom sample, stratified
Ontario
14,750
Students (aged 14-18), Grades 8-12
British Columbia
1988
1.6
Senior students in high schools
U.S.A. national sample
1987 1988
5.6 1.4 (lifetime)
1986 1987 1988
4.1 4.0 3.1 (past Year)
1987 1988
1.5 1.6 (past 30 days)
Chamberlayne et al. [9]
Johnston ef al. [lo]
Johnston et al. [ 101
College students, 1-4 years beyond high school
U.S.A. national sample
1986 1987 1988
1.3 2.0 1.4 (past year)
Washton er al. [4]
458
Cocaine abusers calling cocaine hotline
U.S.A
1986
32.0% (ever)
Inciardi [3]
254
Street youths involved in drugs and crime
Miami
1986
95.5 (tried) 87.3 (regular use)
Wish er al. [ 1I]
250
Intensive supervision of probationers
Brooklyn
1986
38.0% (ever)
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higher among seniors in American high schools. In 1987, 5.6% had used cocaine in their lifetime, 4.0% in the past year, and 1.5% in the past month. However, rates of use were much lower among college students; only 2.0% had used in the past year. Among high school seniors, about 27.1 % of students who reported some cocaine use (lifetime) reported crack use. Only Johnston ef al.’s annual studies [lo] of high school seniors give any indication of trends in crack use. Both crack and cocaine use dropped significantly between 1987 and 1988. Crack was not included in the surveys before 1986, and hence data are not available for the early years of the crack epidemic. However, this study did show a large increase in cocaine smoking between 1983 and 1986. As expected, crack use is very high among high-risk or known drug-using groups. For example, Washton et al. [4] found that 32% of cocaine users calling a cocaine hotline had used crack. One study of intensive supervisionprobationers in Brooklyn showed that 38 % had used crack [111. However, 96% of street youths involved in drugs and crime in Miami used crack, often very heavily, although much of their cocaine use does not involve crack [3]. In general, crack use rates are low in general populations, far lower than for alcohol, cannabis, or tobacco, and even for the use of cocaine in other forms. However, rates of crack use are much greater in some high-risk groups, although in some a minority of cocaine users have tried crack.
CHARACTERISTICS OF CRACK USERS Several studiesof crack users have establishedthat they share many characteristics with users of other types of cocaine. Typically, they are young males who are heavy users of cocaine and other drugs. For example, the study of adults in Ontario [8] established that most crack users were male, aged 18-29, as were most other cocaine users. Many were heavy users of cannabis, sleeping pills, and alcohol. Smart [12] compared student crack users with other cocaine users and with noncrack and cocaine users. Crack users were younger than the other two groups (average age 14.5), and about 75% were male. They were much more likely than nonusers of cocaine to have used all illicit drugs, but especially cannabis, stimulants, and hallucinogens. They were also more likely to smoke cigarettes and drink alcohol frequently. As expected, crack users were similar to other cocaine users in their heavy use of alcohol and most illicit drugs. However, they were more likely than cocaine users to have used PCP, tranquilizers, stimulants, heroin, and glue. Their relative youth and heavy drug use indicates that many student crack users will have problems requiring treatment.
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CRACK COCAINE USE
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The studies of American high school seniors in 1987 [9] also found that crack users are more often male, although use rates for females are relatively close (4.8% males vs 3.1 % females). About one-third of those who had tried crack had stopped using it. Regional differences in crack use were about the same as for cocaine with the highest rates in the West and Northeast, and the lowest in the South. Rates of use were higher in large cities than small cities or nonurban areas, but the differences were not very large. Students who were not intending to go to college were more often users than those who did intend to go to college. Callers to the cocaine hotline who reported crack use [4] were mostly male (72%) and aged 20 to 39 (94%). Most had switched to crack after trying intranasal cocaine. About 82 % reported a compulsion to use the drug, and hence the callers were primarily dependent upon cocaine and not recreational users. Of course, callers to the hotline were primarily seeking help or advice about drug problems and would be expected to be heavier users than those found in general population surveys. Data on crack users in treatment are not very extensive yet as insufficient time has elapsed since crack became popular. One study of 3 1 crack users in a Brooklyn center for medical detoxification [13] found that the ratio of males to females was closer than in most surveys (almost 1: 1). The mean age was 30.6 years. The majority were from Black or Hispanic minorities. Only 32.5% were currently employed, but about 25 % had some employment in the past year. Many had been exposed to domestic violence or alcoholism. In addition, 39% met the DSM 111 criteria for major depression or dysthmic disorder. Earlier studies 1141 found that about a third of cocaine users in treatment are severely depressed. Crack users in other types of treatment in different locales may, of course, show other sociodemographic and psychological characteristics from those in this study.
EFFECTS OF CRACK COCAINE Cocaine increases heart rate, pulse, blood pressure, respiration rates, and creates a general autonomic stimulation. It also creates vasoconstriction. The psychological effects of cocaine are feelings of stimulation, euphoria, hyperactivity, increased talkativeness, and energy [l-31. However, several cases have been reported where cocaine had a calming effect on anxiety or appeared to have a sedative effect [15]. Numerous neurological problems from cocaine use have appeared. For example, CNS stimulation, decreased cerebral metabolism and cases of seizures [11, intracerebral hemorrhage [17], sudden death [16,18], psychosis [19], stroke [20],
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and cardiac abnormalities [21] have been reported from cocaine use. In addition, maternal cocaine use has resulted in decreased gestational age [22], low birth weight, and increased congenital abnormalities in offspring [23]. Because crack cocaine is potent and rapidly absorbed, its effects on cardiovascular, neurological, and psychological functioning should be more rapid than for intranasal cocaine. Probably the effects are stronger and more rapid than some intranasal cocaine users have seen in the past, and certainly more than first time users have seen. Crack cocaine should produce essentially the same adverse reactions of cocaine; however, such reactions may be more common or more severe. Since crack cocaine is smoked and particles are released into the ambient air, passive cocaine inhalation by nonusers is possible.
ADVERSE EFFECTS OF CRACK ON OFFSPRING OF USERS Several studies of the effects of crack use on offspring have been reported. They are summarized in Table 2. Bateman and Heagarty [24] described four cases involving transient neurological symptoms such as drowsiness, unsteady gait, seizures, etc. in children exposed to passive crack inhalation by parents or other persons. The cases appear to have involved heavy crack smoking in closed rooms and illustrate a special problem for crack which does not exist for other forms of cocaine. LeBlanc et al. [25] described cases of tremulousness, imtability, and muscular rigidity among 38 infants of mothers who used crack during pregnancy. Mothers denied using other forms of cocaine or narcotic drugs. However, four of the mothers were also users of marijuana, five drank alcohol regularly, and four were smokers. Urinalyses were done for 20 infants, and cocaine was present in the urine of 10 symptomatic and 9 asymptomatic infants. Hence it appears that cocaine does not always produce neurological or behavioral abnormalities. As with many crack case histories, the contribution of drugs other than crack is difficult to assess. An attempt to control drug effects was made in the study by Cherukuri et al. [26]. They studied 55 women who used crack cocaine (but not narcotics) during pregnancy, and 55 who used no drugs. The frequency of cocaine use is not stated. Crack-exposed infants had lower gestational age and birth weight, smaller head circumference, and premature rupture of membranes. However, there was no difference in the meconium or in fetal distress. Unfortunately, the possible contribution of other drugs such as alcohol, cannabis, etc. is not clear. In addition, 60% of the crack-using mothers had no prenatal care, and the authors recognize
CRACK COCAINE USE
19
Table 2. Adverse Reactions to Crack in Offspring of Users
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~~~~~~~
~
~~
~
~
~
~~
Authors
N
Patient characteristics
Diagnosisisymptoms
Bateman and Heagarty [24]
2
Girl aged 3% months, boy aged 2 years and 3 months
Transient neurological symptoms (drowsiness, unsteady gait)
2
Boy aged 9 months, boy aged 3 years and 1 1 months
Transitory seizures
LeBlanc ef al. [25]
38
Infants of crack-abusing mothers
Possible influence of alcohol, tobacco, and marijuana by mothers
Cherukuri et al. [26]
55
Females admitting crack use in pregnancy compared to 55 not using
Tremulousness ( n = 15) Irritability ( n = 16) Muscular rigidity ( n = 11) Crack-using mothers more often had early deliveries. Infants had intra-uterine growth retardation, smaller head circumference, and ruptured membranes. 60% of crack-using mothers had no prenatal care Fatal battering by crack-using adults
None stated
Press [27]
3
Children aged 1 month, 2 years, 3 years
Other drug None
Unclear
the possible influence of malnutrition and other social factors. However, they argue that the study underestimates the effect of crack on perinatal outcomes. Violent, aggressive behavior has often been reported to be an outcome of cocaine use [1,2]. A brief report by Press [27] describes the fatal battering of three children aged 1 month to 3 years by crack-using adults (presumably family members). Details about the extent of crack use involved or whether the batterings occurred during such use are not given. The question of the role of other drugs was not raised.
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NEUROLOGICAL AND PSYCHIATRIC ADVERSE EFFECTS Cocaine use has been associated with neurological complications such as seizures [l, 151 and cerebral hemorrhages [17]. However, a variety of neurological problems have also been seen after crack use, and these are summarized in Table 3. Recently, Mody et al. I281 described nine cases of neurological disturbances among crack users. The majority seem to have appeared in heavy users, but in at least three cases they appeared after the first crack use. In most cases the role of other drugs is not clear; but in a few, heavy alcohol use was concomitant with crack use. In three cases the neurological symptoms were almost instantaneous after crack use, but in others there were delays of several hours. There were three cases of generalized tonic-clonic seizures, three of intraparenchymalhemorrhage, and one of ischemic infarct in the fronto-temporal area which are attributed only to cocaine. There are two cases of numbness, arm and leg weakness or paralysis, both probably involving transient cardiac or neurological problems. In one case, recurrent episodes of motor seizures followed the concurrent use of crack and six cans of beer. In another case a crack user who was also an alcoholicexperienced transient ischemic attacks, marked burning sensations, tightening of facial muscles, spinning sensations, buzzing in the ears, and double vision. To illustrate the problems of deciding how difficult it is with mutliple drug users to attribute symptoms to a single drug, it is useful to examine the case presented by Golbe and Merkin [29]. They reported on a 27-year-old man who suffered a cerebral infarction after smoking two vials of crack of unknown size. He drank ‘/z pint of vodka and 2 pints of wine at the same time as he had the crack. Usually, he drank about 150 mL ethanol week (11 drinks) and smoked a pack of cigarettes each day. In addition, there were signs that he had a serious alcohol problem and had been a heavy user of intranasal cocaine. It has been pointed out [30] that the symptoms seen could be due to the use of several drugs other than crack. Although the Golbe and Merkin case may have involved drugs other than crack, similar cases reported by Levine et al. [31] do not. They reported on three cases of headache, language and visual disturbances, two of which did not involve other drugs. However, in the third case the patient had taken an “unknown” quantity of alcohol with the crack. Several studies have reported psychiatric problems after crack use. For example, Price and Giannini [32] reported panic attacks in an unknown number of patients. However, Washton ef al. [4] found that a majority of crack users calling a hotline number reported severe depression, paranoia, irritability, and chest congestion after crack use. Fewer reported chronic cough, violent behavior,
CRACK COCAINE USE
21
and suicide attempts; the fewest reported brain seizures. However, the contribution of alcohol and other drugs is not clear.
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CRACK, HIV INFECTION, AND SEXUALLY TRANSMITIXD DISEASES It has been well established that intravenous cocaine use significantly increases the risk of HIV infection [33, 341. Chiasson et al. [33] found that 35% of daily cocaine users were HIV positive. Cocaine use, syphilis, and HIV positivity were more common among Blacks than Whites. In fact, a genetic theory has been advanced to account for the differences between Blacks and Whites in sero positivity [35]. However, the studies of Chiasson et al. [33] and Hahn et al. [34] refer primarily to intravenous drug use. Crack is not mentioned as a cocaine delivery method associated with HIV positivity or syphilis, nor has any study been found linking these problems. Doubtless, some of the cocaine injectors use crack, but this is unlikely to relate to HIV risk or sexually transmitted diseases. In fact, De Jarlais and Friedman suggested [36] that if cocaine injectors were to switch to crack, that would reduce their HIV risk; however, he found that very few in New York City had done so yet.
OTHER MEDICAL ADVERSE EFFECTS A few studies have reported serious medical consequences of crack use. One case has been seen in which a 25-year-old man used freebase twice in the same day [37]. On admission, he had heart block with dyspnea and chest pain. Similar symptoms were reported for six other patients who used cocaine intravenously or intravasally. Zamora-Quezada er al. [38] reported on skin rash and muscle necrosis following crack use. It was associated with reticulitis, myalgias, and muscle weakness. Pulmonary disease called “crack lung” has been seen after crack use. Kissner et at. [39] treated a 47-year-old woman who had fever, transient lung infiltrates, and brochospasm after a week of heavy crack use. The patient also smoked 1-3 packs of cigarettes per day. “Crack” produces most of the adverse neurological, psychiatric, and cardiac effects of cocaine. However, at least two types of reaction are confined to crack. The pulmonary syndrome called “crack lung” will not occur with other types of cocaine administration, nor will the neurological symptoms seen in children breathing the ambient air in rooms filled with crack smoke.
Golbe and Merkin (291
Infarction of cerebral artery, left side weak, hemirparesis hemianopia, and headache
Generalized tonic-clonic seizures
Male aged 31
1
Male aged 27
Generalized tonic-clonic seizures
Females aged 25 and 27
2
1
Ischemic infarct in left fronto-temporal area Intraparenchymal hemorrhage
Maleaged28
Recurrent episodes including burning sensation in eye, tightening of facial muscles, twisting of mouth, spinning sensation, buzzing in ears, and double vision
Males aged 30 to 34
Male aged 45, chronic alcoholic
1
Several episodes of arm and leg weakness, decreased pain, and touch sensations
1
Male aged 22 smoking crack for first time
I
Pain between shoulders, numbness, weakness, paralysis, and cardiac arrest
Diagnosis/sy mptoms
3
Male aged 24 smoking crack for first time
1
Mody cr al. 1281
Patients characteristics
N
Authors
Table 3. Adverse Neurological, Psychiatric, and Medical Reactions to Crack
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with heavy drinking, use of ibuprofen, smoking
Crack use concomitant
Role of alcohol not ClW
Not stated
Not stated
Other drugs
z
2
3-
rn
Male aged 48
1
1
1
1
Zamora-Quezada er al. [38]
Kissner er al. [39]
Female aged 47
Female aged 20
Maleaged25
caine hotline number
144 crack users calling a co-
No information
Male aged 25
1
1
Male aged 27
1
h e r er al. [37]
Washton er al. [4]
Price and Giannini [32]
LRvine et af. [31]
3 episodes of dyspnea, cough, fever, pulmonary infiltrates, and bronchospasm
Skin rash on lower and upper extremities, reticulitis, myalygias, acroyanosis, and muscle weakness
Chest pain, dyspnea, syncope, and complete heart block
Chest congestion (64%). chronic cough (40%). brain seizures (7%),sever depression (85%), irritability (78%). paranoia (65%), loss of sexual violent desire (58%), memory lapses (a%), behavior (31%), and suicide attempts (18%)
Panic attacks
Headache, nausea, slurred speech, ataxia, and blurred vision
Headache, altered vision, and multifocal abnormalities
loss, and languaged disturbance
Left cortical infarct with headache, hemisensory
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Patient smoked 1-3 packs of cigarettes per day
Not stated
Not stated
Unclear
Not stated
None
Alcohol
None
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Since crack users tend to be users of many illicit drugs as well as heavy drinkers, it is difficult to be sure that all of the reported adverse reactions are due to crack. However, the literature clearly suggests that use by mothers leads to abnormalities in offspring and to various neurological, psychiatric, and cardiac problems in users. Although the number of reported adverse reactions is small, it is growing rapidly. Almost all of the reactions involve male users and mostly heavy users of cocaine. However, there are several cases where the reaction occurred among persons using small amounts and taking crack for the first time. Methods of prevention and treatment of crack use are still needed. No specific methods of treatment have been evaluated for crack users, and most probably receive the usual treatment for cocaine abusers. As crack users tend to be heavy users of many drugs as well as cocaine, they may be more difficult to treat than the average cocaine user. There is a need to educate users and potential users about the serious and unpredictable effects of crack. At least one education program has been developed for crack [40], and it has been used with students in Florida. Effective programs at the school and community levels will certainly be needed in areas where crack use is endemic, but most existing programs seem to pay little attention to crack. There is also a need to monitor changes in levels of crack use, especially in heavy drug-using populations and among young people. REFERENCES [l] Siegel, R. K.,Cocaine smoking, Psychoactive Drugs 14:271-359 (1982). [2] Erickson, P. G., Adlaf, E. M., Murray, G. F., et al., 7he Steel Drug: Cocaine in Perspective, Lexington Books, Lexington, Massachusetts, 1987. [3] Inciardi, J. A., Beyond cocaine: Basuco, crack and other coca products, Contemp. Drug Probl. 14:46-492 (1987). [4] Washton, A. M., Gold, M. S., and Pottash, A. C., “Crack,” early report on a new drug epidemic, Postgrad. Med. 80:52-58 (1986). [5] Snyder, C. A,, Wood, R. W., Graefe, J. R., et al., Crack smoke is a respirable aerosal of cocaine base, Pharmacol. Biochem. Behuv. 29:93-95 (1988). 161 Cone, E. J., and Hemmingfeld, J. E., Premier “smokeless cigarettes” can be used to deliver crack, J. Am. Med. Assoc. 261:41 (1989). [7] Smart, R. G., and Adlaf, E. M., Alcohol and Orher Drug Use among Ontario Adults 1977-1987, Addiction Research Foundation, Toronto, 1987. [8] Smart, R. G .,and Adlaf, E. M., Alcohol and Other Drug Use among Ontario Students in 1987, and Trendr Since 1977, Addiction Research Foundation, Toronto, 1987. [9] Chamberlayne, R., Kierans, W., and Fletcher, L., British Columbia Alcohol and Drug Probl e m Adolescent Survey: 1987, British Columbia Ministry of Health, Victoria, 1988. [ 101 Johnston, L. D., O’Malley, P. M., and Bachman, J. G., Drug Use among American High School Studenrs, College Srudents, and Orher Young Adults: National Trendr through 1987, Washington: National Institute on Drug Abuse, Washington, D.C., 1987.
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[ I l l Wish, E. D., Cuadrado, M., and Martorana, J. A,, Estimates of drug use in intensive probationers: Results from a pilot study, Fed. Probat. W4-16 (1986). 1121 Smart, R. G., Crack cocaine use in Canada: A new epidemic?, Am. J. Epidemiol. 127: 1315-1317 (1988). [ 131 Wallace, B. C., Cocaine dependence treatment on an inpatient detoxification unit, J. Substance Abuse Treatment 4:85-92 (1987). [I41 Gawin, F. H., and Kleber, H. D., Abstinence symptomatology and psychiatric diagnosis in cocaine abusers: Chemical observations, Arch. Gen. Psychiarry 43:107-1 13 (1986). [IS] Byck, R., Cocaine Papers: Sigmund Freud, New American Library, New York, 1974. [I61 Wetli, C. V., and Wright, R. K., Death caused by recreational cocaine use, J. Am. Med. Assoc. 241~2519-2522 (1979). [I71 Schwartz, K. A., and Cohen, J. A,, Subarachnoid hemorrhage precipitated by cocaine snorting, Arch. Neurol. 41:705 (1984). [I81 Smart, R. G., and Anglin, L., Do we know the lethal dose of cocaine?, J. Forensic Sci. 32:303-311 (1987). [I91 Post, R. M., Cocaine psychoses: A continuum model, Am. J. Psychiatry 132:225-231 (1975). [20] Brust, J. C., and Richter, R. W., Stroke associated with cocaine abuse?, N. Y. Srare J . Med. 77:1473-1475 (1977). [2l] Howard, R. E., Heuter, D. C., and Davis, G. D., Acute myocardial infarction following cocaine abuse in a young woman with normal coronary arteries, J. Am. Med. Assoc. 254:95-96 (1985). [22] MacGregor, S. N., Chasnoff, I. J., and Rosner, M., Cocaine use during pregnancy: Adverse perinatal outcome, Am. J. Obsrer. Gynecol. 157:686 (1987). [23] Bingol, N., Fuchs, M., Diaz, V., er al., Teratogenicity of cocaine in humans, J. Pediarri. 110:93 (1987). [24] Bateman, D. A,, and Heagarty, M. C., Passive freebase cocaine (crack) inhalation by infants and toddlers, Am. J. Dis. Child. 143:25-27 (1987). [25] LeBlanc, P. E., Parekh, A. I . , Naso, B., er al., Effects of intrauterine exposure to alkaloidal cocaine (crack), Am. J. Dis. Child. 141:937-938 (1987). [26] Cherukuri, R., Minkoff, H., Feldman, J., er al., A cohort study of alkaloidal (crack) in pregnancy, Obsrer. Gynecol. 72: 147-151 (1988). [27] Press, S., Crack and fatal child abuse, J . Am. Med. Assoc. 260:3132 (1988). [28] Mody, C. K., Miller, B. L., McIntyre, H.B., er al., Neurologic complications ofcocaine abuse, Neurology 38:1189-1193 (1988). [29] Golbe, L. I., and Merkin, M. D., Cerebral infarction in a user of free-base cocaine (crack), Neurology 36:1602-1604 (1986). [30] Levine, S. R., Washington, J. M., Moen, M., et al., Crack associated stroke, Neurology 37: 1093 (1987). [31] Levine, S. R., Washington, J. M., Jefferson, M.F., etal., “Crack” cocaine associatedstroke, Neurology 37:1849-1853 (1987). [32] Price, W. A., and Giannini, A. J . , Phencyclidine and “crack” precipitated panic disorder, Am. J. Psychiarry 144:5 (1987). 1331 Chiasson, R. E., Bacchetti, P., Osmond, D., et al., Cocaine use and HIV infection in intravenous drug users in San Francisco, J . Am. Med. Assoc. 261:561-565 (1989). 1341 Hahn, R. A., Onorato, I. M., Jones, S . , et al., Prevalence of HIV infection among intravenous drug users in the United States, J . Am. Med. Assoc. 261:2677-2684 (1989). 135) Watters, J. K., Observations on the importance of social context in HIV transmission among intravenous drug users, J. Drug Issues 19:9-26 (1989). 1361 De larlais, D. C., and Friedman, S. R., Intravenous cocaine, crack and HIV infection, J. Am. Med. Assoc. 259: 1945-1946 (1988).
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[37] Isner, J. M., Estes, M., Thompson, P. D., et al., Acute cardiac events temporally related to cocaine abuse, N. Engl. J. Med. 3151438-1443 (1986). [38] Zamora-Quezada, J. C., Dinerman, H., Stadecker, N. J., et al., Muscle and skin infarction after freebasing cocaine (crack), Ann. Intern. Med. 108:564-565 (1988). [39] Kissner, D. G., Lawrence, W.D., Selis, J. E., er al., Crack lung: Pulmonary disease caused by cocaine abuse, Am. Rev. Respir. Dis. 136:1250-1252 (1987). [ a ] Rohrer, G. E., Hardley, R., Riordan, G. J., et al., Crack cocaine education in the public schools: A treatment center and the schools unite, J. Alcohol Drug Educ. 32:65-70 (1987).
